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855r form pdf

855r 2026

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The document is a Medicare Enrollment Application (CMS-855R) for the reassignment of Medicare benefits. It outlines the process for individual practitioners to reassign their right to bill Medicare and receive payments for services rendered, or to terminate an existing reassignment. The application must be completed by both the individual practitioner and the organization/group receiving the reassigned benefits, with specific instructions on sections to complete based on the reason for submission. It also includes guidelines for signing, mailing, and maintaining compliance with Medicare regulations.

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Click ‘Get Form’ to open the CMS-855R in the editor.
Begin with Section 1, where you will indicate the reason for submitting this application. Check the appropriate box and provide the effective date.
In Section 2, enter the organization/group information receiving the reassigned benefits. Ensure that all details match those reported to the IRS.
Proceed to Section 3 to fill in your personal details as the individual practitioner reassigning benefits. Include your full name, Social Security Number, and National Provider Identifier (NPI).
If applicable, complete Section 4 with your primary practice location details. This section is optional but recommended for clarity.
In Section 5, provide contact person information if there are questions during processing. This can be a designated representative from your organization.
Finally, complete Section 6 by signing and dating both certification statements as required. Remember to use blue ink for original signatures.

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